5 Malaria is a parasitic disease, spread by mosquitoes. It affects millions of people worldwide, and causes significant illness and mortality. Uncomplicated malaria presents with symptoms such as fever, headache, muscle pain, and vomiting. The parasite has become resistant to a number of previously effective drugs, and so combinations of drugs are used to try increase cure and to prevent further resistance. Artemether-lumefantrine is one such drug combination. This review of trials showed that the six-dose regimen of artemether-lumefantrine was associated with high cure rates and was more effective that most other drug combinations used for uncomplicated malaria. Further research is needed to properly assess adverse outcomes. B A C K G R O U N D Malaria Malaria is a major health problem with at least 300 to 500 million people diagnosed with the illness every year (WHO 2000a). The main cause is Plasmodium falciparum, one of the four species of malaria parasites found in humans. Uncomplicated malaria occurs in the majority of those affected, and is the form of the illness which presents with such symptoms as fever, headache, muscle pain (myalgia), vomiting, mild diarrhoea, anaemia, and enlarged spleen (splenomegaly). In addition, children commonly present with rapid breathing (tachypnoea), cough, and convulsions. Antimalarial drug resistance Resistance to antimalarial drugs emerged in South-East Asia and South America (White 1999a), and then spread to Africa and western Oceania. Sulfadoxine-pyrimethamine has replaced chloroquine as the first-line treatment in some African countries (such as Malawi and Kenya), but resistance to this is now also emerging (WHO 2000a). Resistance to sulfadoxine-pyrimethamine is relatively common in South-East Asia (WHO 2001b), where resistance and declining sensitivity to mefloquine have also been reported (WHO 2000a). Mefloquine is contraindicated in areas of intensive malaria transmission, such as sub-saharan Africa, because its long half life may expose parasites to subcurative doses, which could result in the development of resistant strains (WHO 2000a). Artemisinin drugs, including artemether and artesunate, are now used as first-line treatment in some countries in South-East Asia, but they are recommended only as combination treatment (WHO 2000a). Such combination therapy affords rapid clinical response and higher cure rates when compared with other antimalarial combinations (White 1999a). It is also thought combination therapy may slow the parasite developing resistance to the drug (White 1999b). Artemether-lumefantrine combination The fixed-dose combination of artemether-lumefantrine, called co-artemether, contains 20 mg of artemether and 120 mg of lumefantrine (previously called benflumetol). It was initially developed by scientists at the Academy of Military Medical Sciences in China before the pharmaceutical company Novartis (Switzerland) became a partner and was licensed to market it as Coartem or Riamet. This oral preparation has been designed for use against chloroquine-resistant falciparum malaria. Artemether has a rapid onset of action and is rapidly eliminated from the plasma (half life of two to three hours; Lefèvre 1999). Lumefantrine is cleared more slowly and has a longer elimination half life (approximately 4.5 days; Ezzet 1998). The rationale behind this combination is that artemether initially provides rapid symptomatic relief by reducing the number of parasites present before lumefantrine eliminates any residual parasites. This is thought to minimize development of resistance because the malaria parasites are never exposed to artemether alone (due to its rapid elimination). Although they may be exposed to lumefantrine alone, the probability of resistance developing simultaneously to both drugs used in combination is thought to be low (Bloland 2000). Artemether-lumefantrine also reduces gametocyte carriage and thus should have an impact on malaria transmission (Van Vugt 1998a). There has been some concern about the possible risk of neurotoxicity with artemisinin derivatives that arose from animal studies using high doses of lipid-soluble preparations given intramuscularly (WHO 1999). No serious adverse or persistent neurotoxic adverse events have been documented (Novartis 2005). There has been concern that the lumefantrine component could have adverse cardiac effects due to its similar structure to halofantrine (Bindschedler 2000). Artemether-lumefantrine causes minimal QTc prolongation which was not associated with adverse clinical cardiac events (Novartis 2005). These potential adverse effects have to be considered when assessing the drug combination. Artemether-lumefantrine has been added to the WHO Model list of Essential Medicines and is being promoted in Africa as firstline treatment for malaria by the World Health Organization. The World Health Organization has commended the company for providing the drug at discounted prices for developing countries in malaria endemic areas ( WHO 2001a). Rationale for review Since the first Cochrane Review on artemether-lumefantrine was published (Omari 2002), the six-dose regimen has become the standard, as researchers acknowledged the review findings that the four-dose regimen was associated with treatment failures (Nosten 2003). Trials are generally using the six-dose regimen, with the evidence for the four-dose regimen maintained in a separate Cochrane Review (Omari 2006). This review aims to summarize the existing evidence of the six-dose regimen of artemether-lumefantrine and how it compares with other antimalarial drugs for 2

6 treating uncomplicated falciparum malaria, including mefloquine, sulfadoxine-pyrimethamine, and chloroquine. For our endpoint, we use total failure by day 28 as the primary outcome measure, or day 42 for sulfadoxine-pyrimethamine and day 63 for mefloquine because of their long half lives. In areas where malaria transmission is intense, recurrence of parasites by day 28 could also be due to reinfection, so we also examine the polymerase chain reaction (PCR) which is thought to distinguish between a new infection and recurrence of malaria (recrudescence) due to drug resistance. O B J E C T I V E S To evaluate the six-dose regimen of artemether-lumefantrine for treating uncomplicated falciparum malaria. C R I T E R I A F O R C O N S I D E R I N G S T U D I E S F O R T H I S R E V I E W Types of studies Randomized controlled trials. Types of participants Adults and children with acute uncomplicated malaria, as defined in WHO 2000b, with asexual P. falciparum parasitaemia confirmed using blood slides. Types of intervention Six doses of artemether-lumefantrine administered orally versus standard treatment regimens (single drugs or combinations). Supervised versus unsupervised treatment with the six doses of artemether-lumefantrine. Types of outcome measures Primary Total failure by day 28, day 42 (for sulfadoxine-pyrimethamine), or day 63 (for mefloquine); defined as a recurrent malaria infection with or without clinical malaria. Secondary Total failure, defined as a recurrent malaria infection with or without clinical malaria, by day 7. Total failure, defined as a recurrent malaria infection with or without clinical malaria, by day 14. Total failure adjusted by PCR to exclude new infections by day 28 (recrudescent infections). Parasite clearance time (PCT), defined as the time between commencing treatment and the first negative blood test when negativity persists for more than 48 hours; PCT 50, defined as the time taken for parasites to be reduced to 50% of first test value; and PCT 90, defined as the time taken for parasites to be reduced to 10% of first test value. Fever clearance time, defined as the time between commencing treatment and the temperature returning to normal and remaining normal for more than 48 hours. Gametocyte carriage on days 14 and 28. Gametocyte clearance time, defined as the time taken for gametocytes to disappear (if present in the blood initially) after commencing treatment. Adverse events Adverse events requiring discontinuation of treatment, or are fatal, life-threatening, or requiring hospitalization. Other adverse events. S E A R C H M E T H O D S F O R I D E N T I F I C A T I O N O F S T U D I E S See: methods used in reviews. We attempted to identify all relevant trials regardless of language or publication status (published, unpublished, in press, and in progress). Databases We searched the following databases using the search terms and strategy described in Table 01. Cochrane Infectious Diseases Group Specialized Register (April 2005). Cochrane Central Register of Controlled Trials (CENTRAL), published in The Cochrane Library (Issue 1, 2005). MEDLINE (1966 to April 2005). EMBASE (1974 to April 2005). LILACS (1982 to April 2005). Conference proceedings We searched the following conference proceedings for relevant abstracts: The Third Multilateral Initiative on Malaria Pan- African Conference, 18 to 22 November 2002, Arusha, Tanzania; and the Second European Congress on Tropical Medicine, 14 to 18 September 1998, Liverpool, UK. Researchers, organizations, and pharmaceutical companies We contacted researchers working in the field, the World Health Organization, and the pharmaceutical company Novartis for unpublished and ongoing trials. 3

7 M E T H O D S O F T H E R E V I E W Trial selection Aika Omari (AO) screened the results of the search strategy to identify potentially relevant trials. AO and Carrol Gamble (CG) independently assessed the eligibility of these trials for inclusion in the review using the stated inclusion criteria. Any differences in opinion between the authors were discussed with the third author Paul Garner. Assessment of methodological quality We assessed of the generation of allocation sequence and concealment of allocation as adequate, inadequate, or unclear according to Juni We described who was blinded to the interventions, such as the participants, care providers, or outcome assessors. We assessed the inclusion of all randomized participants in the main effectiveness analysis to be adequate if more than 90% were included in the analysis, inadequate if 90% or less, or unclear. Data extraction AO and CG independently extracted data of trial characteristics including methods, participants, interventions, and outcomes, and recorded the data on standard forms. Where data from the published papers were insufficient or missing, we contacted the trial authors for additional information. Where possible, we extracted data to allow an intention-to-treat analysis (the analysis should include all the participants in the groups to which they were originally randomly assigned). If the number randomized and the numbers analysed were inconsistent, we calculated the percentage loss to follow up. For dichotomous outcomes, we recorded the number of participants experiencing the event in each group of the trial. For continuous outcomes, we extracted arithmetic means and standard deviations and combined means using weighted mean difference for each group where possible. If the data were reported using geometric means, we extracted standard deviations on the log scale, and extracted and reported the medians and ranges. Data analysis We compared the drug with non-artemisinin derivative regimens, other artemisinin regimens, and then other comparisons that examined delivery. Adverse events from all trials were reported together. We analysed data using Review Manager 4.2. We compared outcome measures for dichotomous data using relative risk (RR), which is the risk of achieving an outcome in the artemether-lumefantrine group relative to that in the control group. We used total failure (clinical or parasitological failure by day 28) as our main outcome, and we also conducted analysis excluding reinfection where PCR data were available. As the value of the relative risk is constrained to lie between 0 and 1/CGER (control group event rate), large values of the relative risk are impossible when events are common, so failure is preferred to treatment success. We would consider the DerSimonian Laird random-effects model if there was significant heterogeneity. We intend to explore the following potential sources of heterogeneity using subgroup analyses or meta-regression: participant age (under five years versus five years or more); trial setting (high malaria transmission versus low transmission); and the presence of drug resistance to comparator drug, as new trials become available. Additional trials may allow sensitivity analyses according to blinding, allocation concealment, and whether the trials used an intention-to-treat analysis at a future date. In determining the effectiveness of antimalarial treatment, we intended to extract the results of analyses conducted according to the intention-to-treat principle. This approach is considered to be more pragmatic as it attempts to estimate the effectiveness of the treatment in routine practice rather than in the context of a clinical trial. To allow the intention-to-treat principle to be applied, all participants should be followed for the duration of the trial irrespective of whether or not the treatment course was completed or other protocol deviations. Any reason for dropping out of the trial or being excluded from the trial should be documented (WHO 1996). For total failure with trials that had conducted PCR analysis, we classified the infections into: recrudescent infection (matching genotypes on day 0 and day of recurrence); new infection (different genotypes on day 0 and day of recurrence); and missing values. We intended to conduct a sensitivity analysis around PCR examining the effect of missing data, but there were too few trials for us to do this. D E S C R I P T I O N O F S T U D I E S We identified 31 potentially relevant studies. Nine met the inclusion criteria (see Characteristics of included studies ); one trial was reported across two publications (Van Vugt 2000). We excluded 16 studies, including one reported in two separate publications (Hatz 1998), for the reasons given in the Characteristics of excluded studies. We have requested data since 2003 on four studies from Novartis (cited in Novartis 1999), but have not yet received a response. Trial location Four trials were conducted in Africa, one in each of Burundi (Ndayiragije 2004), The Gambia (Sutherland 2005), Tanzania (Mutabingwa 2005), and Uganda (Piola 2005). The other five trials were conducted in South-East Asia, in Lao Peoples Democratic Republic (PDR) (Mayxay 2004; Stohrer 2004) and in Thailand (Van Vugt 2000; Lefevre 2001; Krudsood 2003). Trial funding Two trials reported that they were sponsored by Novartis (Van Vugt 2000; Lefevre 2001). Other trials were funded by the Gates Malaria Partnership (Mutabingwa 2005; Sutherland 2005), the UNDP/World Bank/Special Programme for Research and Training in Tropical Diseases (Krudsood 2003), the Wellcome Trust 4

8 (Mayxay 2004; Sutherland 2005), the World Health Organization (Ndayiragije 2004), USAID (Stohrer 2004), the Medical Research Council, UK (Sutherland 2005), and Médecins Sans Frontières (Piola 2005). Participants Four trials included 2933 children (Mayxay 2004; Ndayiragije 2004; Mutabingwa 2005; Sutherland 2005), three included 1265 adults and children (Van Vugt 2000; Stohrer 2004; Piola 2005), and two trials included 349 participants over 13 years of age (Lefevre 2001; Krudsood 2003). Interventions Two trials had more than two arms: chloroquine plus sulfadoxinepyrimethamine and mefloquine plus artesunate were the comparators in Mayxay 2004; and amodiaquine, amodiaquine plus sulfadoxine-pyrimethamine, and amodiaquine plus artesunate were the comparators in Mutabingwa Two trials each compared artemether-lumefantrine with chloroquine plus sulfadoxine-pyrimethamine (Mayxay 2004; Sutherland 2005) and amodiaquine plus artesunate (Ndayiragije 2004; Mutabingwa 2005).Other comparisons were with dihydroartemisininnapthoquine-trimethoprim (Krudsood 2003), artesunate plus amodiaquine (Ndayiragije 2004), amodiaquine (Mutabingwa 2005), and amodiaquine plus sulfadoxine-pyrimethamine (Mutabingwa 2005). Mefloquine plus artesunate was the comparator in four trials (Van Vugt 2000; Lefevre 2001; Mayxay 2004; Stohrer 2004). One trial compared supervised and unsupervised treatment with artemether-lumefantrine (Piola 2005). Dose and regimen All trials administered the six doses over 72 hours. Children received between 3.8 and 16 mg/kg of artemether and between 48 and 96 mg/kg of lumefantrine; adults received 480 mg of artemether and 2280 mg of lumefantrine. Antimalarial drug resistance Chloroquine resistance and sulfadoxine-pyrimethamine resistance were reported in trials conducted in Tanzania, Burundi, The Gambia, Uganda, and Lao PDR. Multiple-drug resistance was reported in Thailand. Outcome measures (see Table 02) Total failure (illness with parasitaemia or parasitaemia detected by day 28) was the most frequently reported outcome (six of the nine trials). Two trials reported failure by day 42 (Mayxay 2004; Stohrer 2004). Trials also reported the number of treatment failures at other time points (days one, two, three, seven, and 14). Fever clearance was reported in three trials, and time to parasite clearance was reported in three trials. Gametocyte carriage was reported in eight trials and gametocyte clearance in two trials. Polymerase chain reaction (PCR) analysis was reported in seven trials, and all trials reported adverse events. M E T H O D O L O G I C A L Q U A L I T Y See Table 03 for the assessment and the Characteristics of included studies for details. Generation of allocation sequence All the trials were reported as randomized. Two trials reported using an adequate method to generate the allocation sequence. The remaining seven trials mentioned randomization, but they did not report how they generated the allocation sequence. Concealment of allocation Allocation concealment was adequate in the six trials that used central randomization, or numbered, sealed, opaque envelopes. The other three trials did not describe the method used to conceal allocation. Blinding One trial was single blind in which all staff apart from those in recruiting clinic and field assistants were not aware of the treatment group. The remaining eight trials were described as open. Inclusion of randomized participants in the analysis None of the nine trials had complete data for all participants randomized into the trial for the duration of follow up. This was partly because researchers stopped follow up after a participant withdrew. Therefore an intention-to-treat analysis was not possible for the trial investigators or for this review because data necessary for an intention-to-treat analysis were not collected. All trials gave results of analyses based on evaluable participants, that is, participants still on treatment at each time point. Three of the trials, however, also claimed to have reported cure rates as an intention-to-treat analysis (Lefevre 2001; Mayxay 2004; Sutherland 2005) These are not the results of an intention-to-treat analysis, and differed from their evaluable participants analysis by assuming that all participants withdrawn from treatment or lost to follow up still had parasitaemia at all remaining time points. At the end of follow up, the number of participants evaluable for the primary outcome was greater than 90% in six trials and 85% to 90% in three trials. R E S U L T S 1. Versus non-artemisinin derivatives 1.1 Amodiaquine (789 participants, 1 trial) Mutabingwa 2005, conducted in Tanzania, reported fewer total failures with artemether-lumefantrine on day 28 (RR % CI 0.26 to 0.34; 724 participants, Analysis 01.01) and day 14 (RR 0.03, 95% CI 0.01 to 0.05; 750 participants, Analysis 01.02). Gametocyte carriage on day 14 was lower for artemether-lumefantrine (RR 0.32, 95% CI 0.18 to 0.56; 461 participants, Analysis 01.03). 1.2 Chloroquine plus sulfadoxine-pyrimethamine (717 participants, 2 trials) 5

9 Chloroquine plus sulfadoxine-pyrimethamine was one of two comparators in the trial from Lao PDR (Mayxay 2004), and was the only comparator in the trial in Gambian children (Sutherland 2005). Sutherland 2005 reported on the outcome measures on days 28, 14, and 7, while Mayxay 2004 only reported on day 42. Fewer total failures occurred in the artemether-lumefantrine group, but the results were not statistically significant by day 42 (RR 0.95, 95% CI 0.48 to 1.87; 216 participants, Analysis 02.02), day 28 (RR 0.90, 95% CI 0.46 to 1.77; 427 participants, Analysis 02.01), day 14 (RR 0.44, 95% CI 0.11 to 1.74; 435 participants, Analysis 02.02), or day 7 (RR 0.22, 95% CI 0.01 to 3.48; 410 participants, Analysis 02.02). Mayxay 2004 reported that the parasite clearance time was significantly (P < 0.001) faster with artemether-lumefantrine (2.08 days, 95% CI 2.0 to 2.1; 107 participants) than chloroquine plus sulfadoxine-pyrimethamine (2.9 days, 95% CI 2.8 to 3.0; 102 participants); see Table 05. The mean fever clearance time was also statistically significantly (P < 0.001) faster with artemether-lumefantrine (23.1 h, 95% CI 20.9 to 25.3; 107 participant) compared with chloroquine plus sulfadoxine-pyrimethamine (40.2 h, 95% CI 35.9 to 44.4; 102 participants); seetable 06. Sutherland 2005 reported that gametocyte carriage was lower with artemether-lumefantrine by day 28, day 14, and day 7 (Analysis 02.03). Mayxay 2004 reported that five of 100 participants in the artemether-lumefantrine group, and 28 of 110 participants in the chloroquine plus sulfadoxine-pyrimethamine were carrying gametocytes after treatment. 1.3 Amodiaquine plus sulfadoxine-pyrimethamine (1026 participants, 1 trial) Mutabingwa 2005 reported fewer total failures with artemetherlumefantrine on day 28 (RR 0.36, 95% CI 0.32 to 0.42; 948 participants, Analysis 03.01) and day 14 (RR 0.05, 95% CI 0.02 to 0.11; 978 participants, Analysis 03.02). Gametocyte carriage on day 14 was lower for artemether-lumefantrine (RR 0.23, 95% CI 0.15 to 0.37; 617 participants, Analysis 03.03). 2. Versus other artemisinin derivatives 2.1 Amodiaquine plus artesunate (1329 participants, 2 trials) The trials in Burundi and Tanzanian used this comparator (Ndayiragije 2004; Mutabingwa 2005). On day 28, there were statistically significantly fewer total failures with artemether-lumefantrine in Mutabingwa 2005 (RR 0.56, 95% CI 0.48 to 0.66; 957 participants, Analysis 04.01). On day 14, there were fewer parasitological failures in both trials (RR 0.11, 95% CI 0.05 to 0.23; 1283 participants, Analysis 04.02). On day 14, gametocyte carriage was significantly lower with artemether-lumefantrine in Mutabingwa 2005, there was little difference in Ndayiragije The overall meta-analysis showed an effect (RR 0.56, 95% CI 0.35 to 0.91; 941 participants, P = 0.27, Analysis 04.03). Ndayiragije 2004 also reported gametocyte carriage on day 7; it was lower with artemether-lumefantrine (RR 0.68, 95% CI 0.33 to 1.41; 290 participants, Analysis 04.03). 2.2 Mefloquine plus artesunate (419 participants, 4 trials) Two of the four trials that used these antimalarials were conducted in Thailand (Van Vugt 2000; Lefevre 2001). The other two were conducted in Lao PDR (Mayxay 2004; Stohrer 2004); mefloquine plus artesunate was one of the three comparators in Mayxay Total failure by day 28 was more common with artemether-lumefantrine in the two trials that measured this (Van Vugt 2000; Lefevre 2001), but the results individually and in a meta-analysis did not demonstrate a significant difference (RR 4.20, 95% CI 0.55 to 31.93; 389 participants, P = 0.81, Analysis 05.01). Of the 11 participants with parasitaemia on day 28, 10 had a PCR analysis to identify new infections from recrudescent infections; the analysis showed that only two were new infections (Analysis and Table 04). On day 42, more participants treated with artemether-lumefantrine had treatment failures in Stohrer 2004 and Mayxay 2004, and the difference was significant with meta-analysis (RR 2.93, 95% CI 1.48 to 5.80; 315 participants, P = 0.10, Analysis 05.03). All participants with parasitaemia on day 42 in Stohrer 2004 had a PCR analysis to identify new infections from recrudescent infections (Analysis 05.04). All eight failures in the mefloquine plus artesunate group were new infections, and of the 13 failures in the artemether-lumefantrine group, 10 were new infections and three were recrudescent infections (Table 07). Mayxay 2004 reported PCR analysis on day seven but did not separate the treatment groups of 25 failures, 20 were new and five were recrudescent infections. Lefevre 2001 reported no statistically significant difference in the parasite clearance time between artemether-lumefantrine (median 29 h, 95% CI 29 to 32; 164 participants) and mefloquine plus artesunate (median 31 h, 95% CI 26 to 31; 55 participants), although there was no statistical test reported. In Mayxay 2004, parasite clearance times were similar between artemether-lumefantrine (2.08 days, 95% CI 2.0 to 2.1; 107 participants) and mefloquine plus artesunate (2.07 days, 95% CI 2.0 to 2.1; 110 participants) (P value not reported); see Table 05. Lefevre 2001 reported a median fever clearance time of 29 hours (95% CI 23 to 37; 76 participants) for artemether-lumefantrine compared with 23 hours (95% CI 15 to 30; 29 participants) for mefloquine plus artesunate, with no statistical test reported. Mayxay 2004 reported that the mean fever clearance times were similar for artemether-lumefantrine (23.1 h, 95% CI 20.9 to 25.3; 107 participants) and mefloquine plus artesunate (24.6 h, 95% CI 21.8 to 27.3; 110 participants) (P value not reported); see Table 06. 6

10 Lefevre 2001 and Stohrer 2004 reported gametocyte clearance times. In Lefevre 2001, the median time for artemether-lumefantrine was 72 hours (95% CI 34 to 163; 26 participants) compared with 85 hours (95% CI 46 to 160; 10 participants) for mefloquine plus artesunate. As the confidence intervals overlap, it is unlikely the difference between the two groups is significant. In Stohrer 2004, the mean gametocyte clearance time for artemetherlumefantrine was 10.5 days (95% CI 4.35 to 16.65; 47 participants) compared with 7.0 days (95% CI 7.0 to 7.0; 53 participants) for mefloquine plus artesunate; P = 0.6 with Mann-Whitney U-test; seetable 08. Stohrer 2004 and Mayxay 2004 also reported on gametocyte carriage on day 7. In Stohrer 2004, it was higher with artemetherlumefantrine (RR 1.35, 95% CI 0.44 to 4.15; 100 participants, Analysis 05.05). Mayxay 2004 reported that the numbers of participants carrying gametocytes after treatment was 5/100 for artemether-lumefantrine and 4/110 for mefloquine plus artesunate; no time point was given so it was not possible to include this in a meta-analysis. Van Vugt 2000 and Lefevre 2001 reported gametocyte carriage within the first 72 hours; there was no significant difference in carriage between the groups (RR 1.09, 95% CI 0.58 to 2.06; 240 participants, P = 0.18, Analysis 05.05). 2.3 Dihydroartemisinin-napthoquine-trimethoprim (DNP) (130 participants, 1 trial) Krudsood 2003, which was conducted in Thailand, reported equal numbers of parasitological failures in both groups on day 28 (RR 2.35, 95% CI 0.15 to 36.54, Analysis 06.01). This result was not statistically significant, but it is imprecise due to the wide confidence interval. The trial authors reported no statistically significant difference (P = 0.18) between the groups in the mean parasite clearance times for artemether-lumefantrine (48.1 h; 34 participants) compared with DNP (43.0 h; 80 participants) (Table 05). This was also the case for the mean fever clearance times (P = 0.35): 41.2 hours (34 participants) for artemether-lumefantrine compared with 32.8 hours (80 participants) for DNP (Table 06). 3. Supervised versus unsupervised treatment (957 participants, 1 trial) Piola 2005, conducted in Uganda, compared supervised with unsupervised treatment with artemether-lumefantrine. There was no statistically significant difference in the number of total failures by day 28 between the groups (RR 1.18, 95% CI 0.47 to 2.98; 918 participants, Analysis 07.01). 4. Adverse events All nine trials reported adverse events. The majority of adverse events reported were mild or moderate (Table 09), although some were severe (Table 10). One trial published adverse cardiac events separately and reported no clinically significant changes in the electrocardiographic intervals (Van Vugt 2000). One trial reported cardiac monitoring (Lefevre 2001), and one reported no difference in the QTc interval (difference between the longest and shortest measurable interval on the 12 lead electrocardiogram, corrected for heart rate) between treatment groups (Lefevre 2001). D I S C U S S I O N Trial methods The methodological quality of several of the included trials was below average given current standards. Seven of the nine trials did not describe the method used to generate the allocation sequence and three did not describe how allocation was concealed. In seven trials, 90% or more of the participants were included in the final analysis for the reported primary outcome. The intention-totreat analysis for the primary outcome reported in five trials was actually a limited form of sensitivity analysis because they made the assumption that all participants lost to follow up were treatment failures. As results were not based on an intention-to-treat analysis, they are subject to attrition bias and the clinical effectiveness may be biased. PCR analysis Data for failure by day 14 and day 28 were corrected for new infections with missing samples or failed tests classified as treatment failures. This had a minimal effect for mefloquine plus artesunate and the result remained statistically insignificant in favour of mefloquine artesunate. Although PCR results were reported in seven trials, results from different groups were combined making it difficult to draw any valid conclusions and PCR data were not reported on all treatment failures. Non-artemisinin therapies The results of a Cochrane Review of the four-dose regimen showed that it was often less effective than other standard treatment regimens (Omari 2006). The review included a trial comparing fourdose and six-dose regimens, and the six-dose regimen had fewer treatment failures, and this was statistically significant. The six-dose regimen of artemether-lumefantrine performed better than amodiaquine and amodiaquine plus sulfadoxine-pyrimethamine. Total failure was lower with artemetherlumefantrine compared with chloroquine plus sulfadoxinepyrimethamine in two trials, but this was not statistically significant. Background resistance to chloroquine and sulfadoxinepyrimethamine in both trial areas could have affected the performance of the non-artemisinin combination. One of the trials, Sutherland 2005, did not report outcomes on day 42, which would have been more informative due to the long half life of sulfadoxine-pyrimethamine. Parasite and fever clearance times were shorter for artemetherlumefantrine when compared with chloroquine plus sulfadoxinepyrimethamine, which suggests that clinical symptoms may resolve faster. 7

11 Artemisinin combination therapies In comparisons with other artemisinin-combination therapies, fewer participants failed treatment with artemether-lumefantrine compared with amodiaquine plus artesunate. However, the combination of mefloquine and artesunate was more effective at reducing parasitological failure on days 28 and 42. None of the trials reported outcomes on day 63 despite the long half life of mefloquine. There was no difference in parasitological failures between artemether-lumefantrine and dihydroartemisinin-napthoquine-trimethoprim, but the trial may have been too small (130 participants) to detect any statistically significant difference. There was no difference in the parasite, fever, and gametocyte clearance times in comparisons with mefloquine plus artesunate and dihydroartemisinin-napthoquine-trimethoprim. This is not surprising due to the artemisinin component in both therapies. Supervised versus unsupervised treatment Artemether-lumefantrine given without supervision (which is normal clinical practice) showed no difference in the failure rate compared with supervised delivery. Clearance times Trials reported clearance times as medians, percentiles, and means. It would have been more informative reporting these as time-toevent analyses, as data on participants who did not reach the event would have been included in the analysis. Adverse events In some trials where adverse events were reported, no distinction was made between the treatment groups thereby making comparisons impossible. Although some trials reported adverse cardiac events, the evidence was insufficient to address concerns about the possible risk of cardiotoxicity. We, therefore, cannot justifiably comment on adverse events reported apart from reporting the details. A U T H O R S Implications for practice C O N C L U S I O N S The six-dose regimen of artemether-lumefantrine is associated with fewer failures and may be a suitable alternative to amodiaquine, amodiaquine plus sulfadoxine-pyrimethamine, and amodiaquine plus artesunate. Available data suggest that mefloquine plus artesunate is as effective and possibly superior to artemether-lumefantrine. The comparative effectiveness of artemether-lumefantrine was evaluated in a health service setting and the cure rates with unsupervised administration are acceptable. Implications for research Trials should be of high quality, with careful attention to concealment of allocation. All participants should be followed up for the duration of the trial regardless of withdrawal from treatment or other protocol violations as this would permit an intentionto-treat analysis. Reasons for all treatment withdrawals should be documented. Where possible, PCR analysis data should be reported on all treatment failures; if this is not possible, explanations should be given. Results from different groups should be reported separately. P O T E N T I A L I N T E R E S T C O N F L I C T O F Paul Garner and Carrol Gamble (né Preston) were unpaid technical advisers to a World Health Organization meeting on 19 and 20 February, 2001 considering efficacy and effectiveness studies of co-artemether-lumefantrine. The World Health Organization paid for their travel and accommodation, and a representative of Novartis chaired the meeting. Aika Omari: none known A C K N O W L E D G E M E N T S This document is an output from a project funded by the UK Department for International Development (DFID) for the benefit of developing countries. The views expressed are not necessarily those of DFID. S O U R C E S O F S U P P O R T External sources of support Department for International Development UK Internal sources of support Liverpool School of Tropical Medicine UK 8

CHAPTER 7 SUMMARY Anaemia is an inevitable consequence of Plasmodium falciparum malaria infection, especially in areas of high malaria transmission. In these settings, the group at highrisk for malaria-associated

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